Positive change

The narrative in recent years regarding the climate crisis has shifted from planetary health to human health. The health impacts (see Table 1) hit home when The Lancet described the climate emergency as the largest existential threat to human health of the 21st century1 . Healthcare is the largest public sector industry2 and so by default becomes a hefty carbon emitter, contributing to 4% of the UK’s carbon footprint.

As a high-turnover surgical specialty, dentistry is resourceintensive in its use of materials and waste generation. Carbon footprinting has been attempted and the annual 675 kilotonnes of carbon dioxide equivalent (CO2eq) produced in primary dental care is likely to be underestimated, as data is NHS-specific3

The growing demands of aesthetic dentistry will inevitably contribute to the increase in the carbon burden, but further work is required to capture the true picture. Nevertheless, rethinking the way dental care is delivered is essential in addressing dentistry’s environmental challenges, which may be achieved in the following ways.

Identifying Carbon Hotspots

Carbon hotspots can be identified by taking into account carbon emissions of the patient pathway. This differs from medicine, as the major source of carbon emissions in dentistry is thought to be staff/ patient travel and energy use (see Figure 1).

Energy consumption is one of the biggest financial pressures the nation is facing and so energy efficiency has a two-fold benefit. Both financial and environmental energy savings can be achieved by good insulation to help maintain heat, switching to LED lighting and turning devices off when not in use. Switching to a green energy supplier that invests in renewable energy sources is a simple yet effective way of committing to sustainable purchasing practices.

Reducing Waste

Segregation of waste can affect energy utilisation and where waste ends up. Unfortunately, due to local contracts many dental practices use infectious waste bags (orange, intended for known infectious patients only) even though the majority of clinical waste could be placed in the offensive waste stream (yellow tiger bag for non-infectious clinical waste), which is less carbon-emitting.

Ensuring that clean packaging is discarded in domestic or recycling bags avoids the need to treat at higher temperatures. However, emphasis should be placed on reducing waste overall as the recycling process has its flaws.

The number of disposable instruments and products available for dental use is growing, creating significant waste. When choosing alternatives to disposable items, life cycle assessments (LCAs) can establish whether switching to reusable items is a ‘greener’ option. The LCA takes into account the embodied emissions of items from raw-material extraction, manufacturing, shipping over long distances and disposal. Reusing autoclavable instruments, however, is generally the preferred option4 Since the COVID-19 pandemic, at least 19.8 billion items of PPE have been distributed to Health and Social Care services5, contributing to microplastic pollution6 While PPE is important in protecting patients and

8% 19% 30% 31%

0.9% 8% 19% GAS

References

1. Watts N et al. Health and climate change: Policy responses to protect public health. Lancet. 2015; 386(10006): 1861–1914

2. Tomson C. Reducing the carbon footprint of hospital-based care. Future Hosp J. 2015; 2(1): 57–62.

3. Public Health England. Carbon modelling within dentistry: Towards a sustainable future. London: Crown; 2018.

4. Rizan C et al. Plastics in healthcare: Time for a re-evaluation. J R Soc Med. 2020 February 7; 13(2) 49–53.

5. Department of Health and Social Care.

Official Statistics staff, its use must be appropriate to ensure minimal waste. An example of this is using sterile gloves (which have a much higher carbon footprint7) for non-sterile procedures such as extractions. Reusable textiles such as gowns, Type IIR masks and surgical hats are available and offer a cost-efficient alternative to single-use disposable PPE. This change can be implemented relatively quickly in general dental practice. For those who work in NHS Trusts and organisations, liaison with infection control and estates teams would be required.

The use of digital technology also helps to reduce waste associated with paper, films, materials and transportation of goods (see Figure 2) and should be considered to improve patient workflow.

Encouraging Active Travel And Prevention

A large proportion of the dental carbon footprint is linked to staff and patient transport. Therefore, the promotion of active travel can help mitigate travel-related emissions, contribute to better air quality and encourage public health though physical activity.

This may not be as practical in rural areas, where car use is the most feasible option, so exploring electric vehicle use or car-sharing within the team could be considered. Preventing poor dental health reduces the reliance on dental resources and travel to clinics.

Empowering patients to take control of their oral health as part of social prescribing is a powerful tool. As a trusted voice, dental care professionals can be highly influential, especially on social media platforms. Committing to dental environmental sustainability sends a clear message to peers, patients and the public that climate change is a real health threat that everyone needs to take seriously. Acting locally or nationally by working with Royal Colleges and dental networks to influence change can help create a sustainably savvy dental workforce.

Medicine Management

Medicines and anaesthetic cases make up around 25% of the NHS carbon footprint. Nitrous oxide is 298 times more potent as a greenhouse gas than CO2, so its use has gained widespread attention. Most dental clinics that provide inhalation sedation use nitrous oxide supplied in cylinders, which eliminates the problem of pipe-leaking associated with gas manifolds in larger Trusts. Ensuring cylinders are almost empty before return reduces unnecessary expulsion into the atmosphere.

Experimental statistics – personal protective equipment distributed for use by health and social care services in England: 1 March to 31 March 2022. Updated 13 October 2022. www. gov.uk.

6. Adyel TM. Accumulation of plastic waste during COVID-19. Science. 2020; 369 (6509): 1314–1315.

7. Journal of Hospital

Infection

Jamal H et al. Non-sterile examination gloves and sterile surgical gloves: which are more sustainable? 2021; 118: 87–95.

1. Virtual appointments

Where intra-oral assessment is not essential/possible (e.g. results/uncooperative patient). They also reduce staff/patient travel

2. Digital notes and radiographs

These reduce the need for paper,chemicals and films. Can facilitate communication

3 Digital scanners

These improve accuracy and eliminate the need for impression/lab materials and lab transplant

4. digital communication

Encrypted email communication facilitates patient care and avoids paper and postage

5. Virtual CPD

This reduces the need to travel. Also has financial and social added value.

Unused and expired medicines enter water and food streams if they are not discarded properly. Reducing prescription days could help avoid this and regularly checking expiry dates of medicines in the surgery may ensure efficient use of stock.

Dentistry Without Harm

The interplay of health provision and disease prevention is a complex one in relation to sustainability. While global action is required to secure a liveable and viable future, we owe it to our patients and communities to reduce the environmental burden by providing dentistry without harm.

Worsening of infectious diseases by 58%

Warm conditions

Cholera in water from multiplying algae

Disease-carrying mosquitoes, e.g. malaria, Dengue fever

Water-borne diseases

Floods

Migration of animals

Air pollution

Migration of populations and spreading of diseases

Virus transmission from animal reservoir to human populations amplifying to epidemics/pandemics

Cardiorespiratory disease